Provider Demographics
NPI:1043522501
Name:SOUTHERN MEDICAL CLINIC
Entity Type:Organization
Organization Name:SOUTHERN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTANI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-497-1347
Mailing Address - Street 1:3700 PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4056
Mailing Address - Country:US
Mailing Address - Phone:614-497-1347
Mailing Address - Fax:614-497-1267
Practice Address - Street 1:3700 PARSONS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4056
Practice Address - Country:US
Practice Address - Phone:614-497-1347
Practice Address - Fax:614-497-1267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002161B261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care